EMTALA, the law that requires ERs to evaluate and stabilize everyone who shows up, is a good law. (There went half my readers right there.) If you’re still with me:

I would argue (as would the writers of EMTALA) that we are so advanced a nation that patients should not be dying on the streets because of their inability to pay for emergency medical care. The problem with EMTALA is that it provides too much potential for abuse. This is the fundamental art of social policy — how do I put together a rule to maximize its use for its intended purposes, yet minimize the opportunities for abuse and loss of personal freedoms for whom the rule applies? (Note: unfortunately many policy makers do not seem to follow or care about this. They trust lobbyists to do this.)

If you were to look online or eavesdrop in a doctor’s lounge, likely “abuse of medical resources by certain patients” would be near the top a frequency-of-complaining list. However if you were to look at how much, in reality, these patients actually cost the system, it would be a tiny percentage of that compared to the truly sick. So it’s more a matter of wasting a doctor’s time and energy — these patients are truly draining: they frustrate physicians and nurses greatly.

The other problem is that EMTALA is an unfunded mandate. This means that hospitals are required to follow the rules of EMTALA no matter what the cost may be to the individual hospital.

Often it depends on why the patient is there — which often is near impossible to discern in the first place. Others are straightforward: hypochrondriacs? Easy. Refer to psych. For drug seekers (note: boy would these patients be easier to spot a mile away if we had some sort of national medical record), make sure they’re only drug-seeking, and get them out.

Others seemingly have nothing better to do. While I’d argue that perhaps job resources, education, and opportunities in the long term and for future generations might be a better solution, I’ll stick to health care for now.

If we want these patients to either stop seeking care altogether (not good to alienate people from the health care system, I’d argue, see my other posts in this series) or start seeking more appropriate care, then we’ve got to use our carrots (rewards) and our sticks (punishments) to lead the donkey.

Maybe we just need to offer better options. For some patients who simply don’t know any better, and for whom a stern lecture by a doctor isn’t going to educate them, they just need another place to go besides the Emergency Department. For these patients, we should be supporting our community health centers for after-hours clinics. They’re usually just as well-placed and located as hospitals, they provide more appropriate care settings at much lower costs, and they would also get a patient tied in for follow-up at the clinic, maybe even start seeing a physician on a regular basis. These after-hours clinics should be funded, like EMTALA (see below).

For other patients, they need a stick, as the niceities of education and better options simply don’t appeal to their finer sensibilities. Two possibilities here: perhaps it’s three strikes out at the olllld ballll game. Once a patient has been seen for non-urgent care (which would obviously need to be defined) three times, they no longer qualify for EMTALA at the hospital. If they return, they get a vital signs screening by a triage nurse, and barring no abnormal vitals or other gross, obvious issues, they are turned away. Another possibility would be charging a patient for non-urgent issues. We say, “Sure, we’re happy to evaluate you,” but if you are not even urgent (remember, you’re at an Emergency Department), you’ll be charged. (Note: this latter option I don’t support if there are no other options for these patients, which is why I think we should offer after-hours clinics.)

Finally, funding. A colleague of mine likes to say that a heavenly program can be hell if not funded appropriately, and maybe this would lead to a chain reaction of EMTALA fixes. If the federal government (read: taxpayers) had to start paying for EMTALA care (note: we already are, in the prices of higher costs to subsidize unreimbursed care), we would immediately see the true costs, and take actions to fix it. Currently, it’s all just buried in inflated prices and percentages of costs and losses in hospital account ledgers. Either way, EMTALA care needs to be funded. Some states are trying to partially fund this effort by passing certain taxes, but a national source makes more sense, since it’s a national law.

(Note: “Repeal EMTALA” enthusiasts are either kidding themselves, heartless, or living on Mars. If you believe that Emergency Departments in the United States should check for insurance in the ambulance bay or require a funds verification before they see a septic patient or one after a bad car accident, like they do in India, you might as well stop reading. We’re not going to see eye-to-eye anyway. For-profit hospitals would have no problem doing this, and it’s unethical and immoral.)

You have to show up with a fanciful complaint SEVERAL times for an ER doctor to refer you to psych. I’ve only seen it happen once so far in my career, and that was after approximately the 10th visit in a month for “inability to swallow and foreign body sensation”. Guy had 6 soft tissue of the neck XRs, scopes, etc etc.

Otherwise, hypochondriacs just show up and get their negative work-up and go home.

Just saying—it’s not “easy” for ER doctors to declare something hypochondria or typical chronic pain, etc, given the legal environment. If someone comes back with a slightly different problem, it will have to be worked up several times and so on and so on. If the problem is in the same location, but slightly different in nature, it is usually worked up as well. If the problem is 100% the same, but hasn’t been worked up in awhile, then they probably get a work-up as well.

This is the same story for hypochondriacal as well as “chronic” patients in general.

You probably haven’t been around the ER enough to see these people come back numerous times and get the same work-ups over and over and same negative results. The doctors all know the work-up will be negative, but don’t want to be the ones to miss something important. Our doctors have plenty of access to clinic records and previous hospital charts, but I think some sort of “national” EMR would be cool but hard to implement.

If they return, they get a vital signs screening by a triage nurse, and barring no abnormal vitals or other gross, obvious issues, they are turned away.

That would be my job, and I’m not taking on the liability. Do I know which problems are non-emergent without doing any diagnostic studies or even an exam beyond vitals? Sure, I’m accurate most of the time just based on talking to the patient. Will I bet my license on it? Nope. Will I consider betting my license on it if no one could sue me? Maybe.

MD2B:

With regards to “frequent flyers”, I have to agree, especially if it was private practice, I’d be nervous to put my license behind a triage nurse who screens and turns away ppl without gross abnormalities on initial exam. Statistically, it is probable that we miss a surgical diagnosis. It is not a reflection of incompetence-there is the occasional patient who doesn’t have a textbook presentation.

It’s a good idea but the reality is that the legal system can be abused. This has paralyzed the implementation of ideas in the typical health care institution. It is very easy to sue a health care professional even if the claim is ridiculous. You can do it with a phone call. So, unless these ideas are protected by some sort of law, they may be a bit tough to implement.

The best thing to do would be to offer the “medical screening exam” and then if no emergency exists (ie you’ve satisfied your EMTALA requirment), require a deposit be paid for treatment or further work-up. No laws would need to be changed for that, only attitudes and habits. The $20 sliding fee clinic looks a lot better for that viral syndrome work-up vs. the $50 deposit for ER treatment of the same thing.

When I was in Europe, there was a ticket guy on the train that walked around with a portable credit card machine and he just swiped your credit card if you needed a ticket. If you’re requiring payment, it should be easy to obtain.

There’s really going to be nothing that stops people from coming to the “free” ER for non-emergent problems unless the “free” ER isn’t free anymore.

Blondie:

I like the idea of pre-screening patients who show up at the ER; although I am not (yet) a physician, I can tell just from my regular patient visits to the ER that a good chunk of the people there really shouldn’t be.

One problem you hinted at yet didn’t come out and say is that we right now have a President who says “Everybody in the US has healthcare; go to the ER!” That philosophy alone causes a multitude of problems (lack of continuity of care, flooding the ERs, the debt accumulation due to unpaid bills, etc). EMTALA needs to be revised so hospitals don’t sink from debt, and people can be directed towards getting the care they really need.

I do feel lucky that we live in a country where the ER will see you because they must. I cannot imagine what it must be like to be evaluated for cash potential before being treated. That whole philosophy ethically and morally despicable.

I cannot imagine what it must be like to be evaluated for cash potential before being treated.

You’ve never been to [most] clinics/urgent cares or [the overwhelming majority] of dentists’ offices? It seems the first thing I do when I arrive at my clinic is pay a co-pay and give them my insurance card.

Just to get my wisdom teeth pulled, I had to throw down $275, for example, and I have relatively decent dental insurance.

When I was uninsured, I went to the Minute Clinic and threw down $30 for the privilege to be seen and treated there for my pink eye or whatever it was that I had.

“If they return, they get a vital signs screening by a triage nurse, and barring no abnormal vitals or other gross, obvious issues, they are turned away.”

Oh, you mean if the regulation is actually followed as it is written? I don’t think there needs to be a modification, just risk alleviation. Fear, expediency, haste and remuneration.

Furthermore, going beyond EMTALA, if we were able to use the judgment we use with cases, to honestly triage patients, we could all but eliminate abuse.

I believe you are correct that the dollar-savings might not be as great as anticipated, but the “shot over the bow” regarding patient responsibility would have a ripple effect that would translate into further cost-savings.

Blondie:

Replying to Nurse K:

I was referencing instances where people are in dire need of medical attention and do not get it because they are uninsured, not whether or not a local clinic asks for your insurance card when you show up with a sinus infection. The other people you mention are trying to stay in business-and I agree that they need to make sure their customers can pay. But I appreciate that we don’t necessarily do that in the ER; having had my own medical emergency once, I’m very glad that they treated me (and saved my life) before asking about my insurance.

(and after reading your blog, I must say that we probably don’t agree on much, if anything! funny how we both end up here)

Blondie: I come here because I’m not afraid to read blogs written by people who have markedly different opinions than I do on health care. Graham wants to work in ER. I am evilly waiting for his opinions to be changed by the reality of starting in some over-crowded county ER somewhere as a resident.

The other people you mention are trying to stay in business

PS: My hospital is a business too and would like to stay in business, thanks. There’s no magic market condition that exists whereby ERs are somehow exempt from going out of business/causing the hospital to go out of business when too many people choose to abuse that particular ER. Most ERs lose money and hospitals have to make up for the lost funds with things like cardiac caths and surgeries/outpatient surgeries that pay out a lot of money (when done on those with some kind of insurance).

John W. Thompson, MD:

Nurse K:
I have had the same thoughts regarding how two to three years of residency in ER Medicine will change Graham’s opinions. There was a time, when I was a senior medical student, that I had some very idealistic opinions. After I finished my residency, which was four years, I wasn’t nearly as idealistic as when I was a med student.

[...] EMTALA, the law forcing emergency rooms to take all comers, “has created the very conditions it sought to avoid” [Edwin Leap, M.D.O.D.] Watch for “free-standing” ERs that dodge mandate by refusing federal dollars [Scalpel or Sword?, Health Care BS] Semi-defense of law [Over My Med Body] [...]

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This is a medical weblog--a collection of thoughts about medicine, medical training, and health policy--written by a fifth-year medical student.

I recently stopped blogging, as I graduated from medical school and I'm now a physician in my residency training in New York City. But feel free to read and enjoy!